CLINICAL REVIEW

S. Annibali1*, M.P. Cristalli1,

D. DellAquila1, I. Bignozzi1,
G. La Monaca1, and A. Pilloni2

Short Dental Implants: A

Systematic Review

Department of Odontostomatological and Maxillofacial

Sciences, Oral Surgery Unit, Sapienza University of Rome,
Via Caserta, 6, 00161-Rome, Italy; and 2Department of
Odontostomatological
and
Maxillofacial
Sciences,
Periodontology Unit, Sapienza University of Rome, Rome,
Italy; *corresponding author, susanna.annibali@uniroma1.it
J Dent Res 91(1):25-32, 2012

ABSTRACT

Growing evidence has suggested the utility of

short dental implants for oral reconstructive procedures in clinical situations of limited vertical bone
height. The aim of this review was to systematically evaluate clinical studies of implants < 10 mm
in length, to determine short implant-supported
prosthesis success in the atrophic jaw. Implant
survival, incidence of biological and biomechanical complications, and radiographic peri-implant
marginal bone loss were evaluated. Screening of
eligible studies, quality assessment, and data
extraction were conducted by two reviewers independently. Meta-analyses were performed by the
pooling of survival data by implant surface, surgical technique, implant location, type of edentulism, and prosthetic restoration. Two randomized
controlled trials and 14 observational studies were
selected and analyzed for data extraction. In total,
6193 short-implants were investigated from 3848
participants. The observational period was 3.2
1.7 yrs (mean SD). The cumulative survival rate
(CSR) was 99.1% (95%CI: 98.8-99.4). The biological success rate was 98.8% (95%CI: 97.899.8), and the biomechanical success rate was
99.9% (95%CI: 99.4-100.0). A higher CSR was
reported for rough-surfaced implants. The provision of short implantsupported prostheses in
patients with atrophic alveolar ridges appears to be
a successful treatment option in the short term;
however, more scientific evidence is needed for
the long term.

KEY WORDS: dental implant, short implant,

success rate, survival rate, literature review, dental
prosthesis, implant-supported.

DOI: 10.1177/0022034511425675
Received May 26, 2011; Last revision September 12, 2011;
Accepted September 12, 2011

INTRODUCTION

ver the years, various strategies have been proposed to overcome the
dimensional limitations of the bone available for implant placement.
Several surgical interventions for bone augmentation have been proposed,
including bone grafts, guided bone regeneration, distraction osteogenesis,
sinus floor elevation, mandibular nerve transposition, and the use of tilted or
zygomatic implants. Although these techniques have gained a degree of success through the years, with the exception of sinus floor elevation, there are
insufficient data on their predictability. Short implants (SHIs) have been proposed as an alternative choice for the prosthetic treatment of atrophic alveolar
ridges, which may provide surgical advantages including reducing morbidity,
treatment time, and costs.
However, longer implants have always been considered more reliable due
to both an improved crown-to-implant ratio and a greater surface area available for osseointegration, which dissipates the imposed occlusal forces.
The introduction in the last decade of modified implant designs and microstructured implant surfaces that augment the integratable surface area could
help to compensate for the adverse effects of decreasing the implant length,
so as to maintain the extent of the bone-implant interface (Goen et al., 2005).
The biomechanical rationale behind the use of SHIs is that the crestal portion
of the implant body is the most involved in load-bearing, whereas very little
stress is transferred to the apical portion (Lum, 1991) and the increase of
implant length from 7 to 10 mm did not significantly improve its anchorage
(Bernard et al., 2003). Therefore, implant length may not be a primary factor
in distributing prosthetic loads to the bone-implant interface. However, the
poor bone density of the atrophic jawbone, the posterior location in the
mouth, and the augmented crown height of the restorations represent important risk factors in the use of SHIs that might jeopardize their survival.
The present study was undertaken to gather and evaluate data from published articles to assess if the provision of short implants in patients with
atrophic alveolar ridges may satisfy the desired outcomes of a successful
implant therapy, as described by the Academy of Osseointegration Guidelines
(2010) (for a detailed description, see Appendix Table 1).
In this review, implants with lengths of less than 10 mm were considered
short.

MATERIALS & METHODS

A supplemental appendix to this article is published electronically only at http://jdr.sagepub.com/supplemental.

Study Selection Criteria

International & American Associations for Dental Research

Study selection criteria were as follows:

25

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Annibali et al.
Studies specifically designed to investigate SHIs.
All types of clinical study designs except for case reports.
Detailed data on implant length.
Implant survival rates clearly indicated or calculable from
the reported data.
Criteria for implant failure clearly defined.
Mean follow-up of at least 1 yr after prosthetic loading.
Only the most inclusive publication from series for which
the same data have been published on multiple occasions.
English language.

Broad inclusion criteria were adopted to render the findings

of this review more general, without distinguishing patient characteristics, implant type, surgical technique, or prosthetic rehabilitations (for a detailed description, see Appendix Table 1).

Search Strategy
We searched the MEDLINE database of the National Library of
Medicine to identify all articles published between January
1966 and December 2010 that contain the following key words:

Short dental implants

Short implants
Dental implants [MeSH term] AND short implants
Dental Implants [MeSH term] AND short length
Dental Implants [MeSH term] AND length.

A supplementary hand search was performed through 6 relevant peer-reviewed dental journals published between January
1990 and June 2009: Clinical Oral Implant Research,
International Journal of Oral and Maxillofacial Implants,
Clinical Implant Dentistry and Related Research (from 1999),
Journal of Periodontology, Journal of Clinical Periodontology,
and International Journal of Periodontics and Restorative
Dentistry, and through the reference lists of all pertinent papers
and review articles.
Titles and abstracts of all identified reports were analyzed by
two examiners.

OUTCOME MEASURES
Outcome measures were as follows:
Implant survival. This refers to the presence of an implant
with or without complications. Failure was defined as
removal of the implant. Implant survival was quantified
here as the cumulative survival rate (CSR) and was calculated on the absolute number of implants placed and lost.
Implant biological success. This refers to the presence of an
implant in the absence of complications of a biological
nature (i.e., persistent pain, neuropathy and/or loss of function, persistent uncontrolled peri-implant inflammation and/
or infection, persistent peri-implant radiolucency, implant
mobility) (AO Guidelines, 2010). The biological success rate
(BScR) was extracted from the publications as the absolute
number of prosthetically restored implants relative (or not) to
the above-defined success criteria. It includes late failures.

J Dent Res 91(1) 2012

Radiographic peri-implant marginal bone loss (MBL).

This was studied as a measure to evaluate progressive
bone loss or increased probing depths.
Implant biomechanical success. This refers to the presence
of an implant in the absence of complications of a biomechanical nature (i.e., prosthesis instability, fractured occlusal materials, fractured or loosened prosthetic components,
implant fracture) (AO Guidelines, 2010). The biomechanical success rate (MScR) was extracted as the absolute
number of prosthetically restored implants presenting (or
not) biomechanical complications.

Data Extraction
Two reviewers independently extracted the data using dataextraction tables. The data extracted included the following:
year of publication, type of study, aim of the study, number of
patients enrolled, numbers and types of implants used, oral location, type of prosthetic restoration, surgical technique used,
follow-up period, survival rate, success rate, biomechanical
complications, and authors comments.

Quality Appraisal
The selected studies were screened for quality assessment. In the
randomized controlled trials, the risk-of-bias was assessed by the
Cochrane Collaboration tool (Higgins and Green, 2011). To
assess the scientific evidence provided by the observational studies, we constructed a quality assessment system on the basis of
previously accepted checklists (Wells et al., 2001; West et al.,
2002; NICE, 2010). A 14-question checklist was completed for
each study. Any disagreement was solved by discussion.

Data Analysis
Agreement between the reviewers was calculated by Cohens k
statistical analysis. The mean follow-up of the selected reports
was calculated as the weighted mean on the number of implants
investigated at each stage of the study. Data were presented at
the implant level. Losses to follow-up were not considered.
CSR were meta-analyzed according to fixed and randomeffects models. Statistical heterogeneity was assessed by means of
the l2 statistic: We reported fixed or random-effects model results
according to the test of heterogeneity (but both can be evaluated
as means of sensitivity analysis). All the analyses were performed
with STATA11 (Statacorp, College Station, TX, USA).

RESULTS
Study Selection and Data Extraction
The MEDLINE search yielded 850 references, 10 were collected from the manual search of the 6 selected journals, and 24
from the reference list of pertinent articles and reviews. Of these
884 papers, 83 were screened as full-text articles. Sixteen studies fulfilled the inclusion criteria (Fig.1; Appendix Table 2)
Agreement in eligible studies selection and data extraction
was unanimous between the two reviewers. The agreement in

J Dent Res 90(1) 2012

Short Dental Implants: A Systematic Review

27

quality assessment was excellent (k =

0.862) (Orwin, 1994).

Study Quality
Two studies were randomized controlled
trials (RCT), and 14 were observational
studies. Overall, the 2 RCTs were wellconducted with respect to randomization,
allocation, blinding, and data collection.
Factors that mostly increased the risk-ofbias were the sample size and the followup duration. One study (Cannizzaro
et al., 2009) had a high risk-of-bias from
group imbalance, since the control group
systematically received implants with a
smaller diameter than those received by the
test group. This might have confounded the
results of the trial, whose objective was to
study the role of implant length on the
implant success rate (Table 1).
Figure 1. Flowchart of the selection of the studies for the review.
Two observational studies were prospective clinical studies, and 12 were
retrospective clinical studies. Five of these were multicenter
(9.8%); the remaining 5253 implants (84.8%) had different types of
studies, while two were reported by single practitioners
rough surface (acid-etched, hydroxyapatite-coated or -blasted,
(Fugazzotto, 2008; Anitua and Orive, 2010). Selection criteria
sandblasted acid-etched, titanium-plasma-sprayed, sintered porous,
and outcomes definition were clearly described in less than half
oxidized, humidified with plasma-rich growth factor). Grant et al.
of the studies. Only one study assessed outcomes blindly. Most
(2009) studied 335 8-mm-long implants, but did not specify surface
papers reported the number of implants monitored at each stage
characteristics.
of study, but only 5 explained reasons for drop-outs. Six studies
did not report a length of follow-up adequate for outcomes to
Implant Location
occur. Three reports presented conflicts of interest. In one multiMost of the implants (n = 5834, 94.2%) were placed in the poscenter study (Misch et al., 2006), the first author was a member
terior regions: 1871 (30.2%) in the posterior maxilla and 3458
of the board of directors and a paid consultant for the implant
(53.8%) in the posterior mandible. Ninety-nine (1.5%) implants
manufacturer, but it was declared that no products, royalties, or
replaced anterior teeth, and 260 (4.1%) were placed into the
reimbursements for any sale were received (Appendix Table 3).
interforaminal region of extremely resorbed mandibles (Friberg
et al., 2000).
Study Characteristics
The data extracted from the studies included in the review are summarized below (for a detailed description, see Appendix Table 4).

Patient Selection
In total, 3848 patients were treated: 1474 were male and 2374
female, with ages ranging from 18 to 94 yrs (mean age, 56 yrs).
The selected patients were usually healthy, and smokers were
included.

Implant Characteristics
We studied 6193 implants. The implant lengths ranged from 5 to
9 mm, the majority being 8 mm long. The implant diameters
ranged from 2.5 to 6 mm. Approximately 298 of all implants
(4.8%) had a diameter larger than 5 mm.
Implant design (e.g., threaded implant, hollow screw, or hollow
cylinder) and surface characteristics varied between studies. Four
studies with 605 implants dealt with machine-surfaced implants

Surgical Procedures
A two-stage operation was used to place 1983 implants (32.3%),
while 3510 (56.7%) were placed by means of a single-stage
surgical technique. A further 685 implants (11%) were placed by
special surgical techniques (i.e., immediate loading, sinus elevation, crest expansion, or reconstructive procedures).

Restoration Type
Only 7 studies used prosthetic restorations supported exclusively by SHIs. All of the other studies collected data from SHIs
standing alone as well as from SHIs splinted to standard
implants. In one study (Goen et al., 2005), it was not clear if
SHIs were splinted to standard implants. In general, singlecrown rehabilitations numbered 2351 implants (37.9%), while
1444 (23.4%) were SHIs splinted together in multiple implant
restorations. The remaining 2398 (38.7%) were probably SHIs
splinted to standard implants.

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Annibali et al.

J Dent Res 91(1) 2012

Table 1. Risk-of-Bias Assessment of the Randomized Controlled Trials Included in the Systematic Review
Reference

Cannizzaro et al., 2009

Felice et al., 2010

Entry

Judgment

Support for Judgment

Judgment

Random sequence
generation

Low risk

Low risk

Patients were randomly allocated, by a

computer-generated randomization list.

Allocation concealment

Low risk

Low risk

Only one of the investigators, who was not

involved in the selection and treatment
of the patients, was aware of the
randomization sequence and had access
to the randomization list stored in his
password-protected portable computer.

Blinding of participants
and personnel

Low risk

Patients were randomly allocated, by a

computer-generated randomization
list.
Only one of the investigators, who was
not involved in the selection and
treatment of the patients, was aware
of the randomization sequence and
had access to the randomization
list stored in his password-protected
portable computer.
Treatment allocation was concealed:
The randomized codes were enclosed
in sequentially numbered, identical,
opaque, sealed envelopes. Envelopes
were opened sequentially after
eligible patients were anesthetized.

Low risk

Blinding of outcome
assessment

High risk

Treatment allocation was concealed:

The randomized codes were enclosed
in sequentially numbered, identical,
opaque, sealed envelopes. Envelopes
were opened sequentially after eligible
patients signed the informed consent to
treatment.
Follow-ups were conducted by an
independent blind outcome assessor
together with the operator, but the
different interventions, and hence group
allocations, were easily detectable.

Incomplete outcome data

Selective reporting

Low risk
Low risk

Other sources of bias:

group imbalance

High risk

Other sources of bias:

sample size inadequacy

High risk

Other sources of bias:

time lag bias

High risk

Follow-ups were conducted by an

independent blind outcome assessor
together with the operator, but the
different interventions, and hence
group allocations, were easily
detectable.
No missing outcome data.
The study protocol is available, and all
of the studys pre-specified outcomes
have been reported in the prespecified way.
Implants in one group had
systematically smaller diameters than
implants in the other group.
The sample of patients recruited
was smaller than the sample size
statistically calculated for the primary
outcome measures.
The short duration of the follow-up
might influence the outcomes.

Follow-up
The duration of follow-up from prosthetic restoration varied
from 1 mo to 14 yrs (mean, 3.2 1.7 yrs). In 8 studies, some
patients were followed for at least 5 yrs. One study (Friberg
et al., 2000) observed 116 implants for more than 10 yrs.

Failure Analysis
One hundred three implants (1.7%) were lost. Thirty-four had a
machined surface, 64 had a rough surface, and 5 were not specified.
Failures were categorized as early (implants that failed before prosthetic loading, 75.5% = 71 implants) and late (implants that failed
after prosthetic loading, 24.5% = 23 implants). The prevalence of
late failures was higher for machined implants. One study (Anitua
and Orive, 2010) did not specify whether failures (9 implants)

High risk

Support for Judgment

Low risk
Low risk

1/30 drop-out from intervention group.

The study protocol is available, and all of
the studys pre-specified outcomes have
been reported in the pre-specified way.

Low risk

The two groups were similar.

High risk

The sample of patients recruited was

smaller than the sample size statistically
calculated for the primary outcome
measures.

High risk

The short duration of the follow-up might

influence the outcomes.

occurred before or after prosthetic loading, but all occurred within

9 mos from implant placement.

Cumulative Survival Rate

The CSR reported in the studies varied from 92.2% at the 1-year
follow-up (Gentile et al., 2005) to 100% after 5 yrs of observation (Griffin and Cheung, 2004). Only Friberg et al. (2000)
produced results for CSRs over time, decreasing from 97.7% at
1-year follow-up to 95.5% at 5 yrs and 92.3% at 10 yrs.

Biological Success Rate

The BScR extracted from the studies varied from 89.5% (mean
follow-up, 3.9 yrs) (ten Bruggenkate et al., 1998) to 100%
(mean follow-up, 4.7 yrs) (Mal et al., 2007; Deporter et al.,

J Dent Res 90(1) 2012

Short Dental Implants: A Systematic Review

29

2008). When the observational period

was augmented (mean follow-up, 8 yrs)
(Friberg et al., 2000), the BScR remained
high (95.3%). Five papers did not report
information available for the analysis of
biological success as described in this
review.

Marginal Bone Loss

Only 6 studies calculated the mean MBL
for the observed implants, while others
(Griffin and Cheung, 2004; Goen et al.,
2005; Fugazzotto, 2008; Grant et al.,
2009) set bone loss limits to quantify
implant success without specifying their
own findings. Ten Bruggenkate et al.
(1998) calculated the MBL at 6-year
follow-up and found no bone loss in
72% of 126 patients, up to 1 mm of MBL
in 16%, up to 2 mm of MBL in 9%, and
more than 2 mm of MBL in 3%.

Biomechanical Complications

Figure 2. Forest plot of Cumulative Survival Rate and subgroup analysis per study design

(mean follow-up, 3.2 1.7 yrs).

Four studies did not observe any biomechanical complication: Two of them did
not go beyond the 1- (Felice et al., 2010)
implant location in the anterior maxilla, but the number of investiand 2-year follow-up (Rossi et al., 2010); the others followed 55
gated implants was too small to be representative.
(ten Bruggenkate et al., 1998) and 230 implants (Mal et al.,
Pooled BScR (according to the random-effects model) was
2007) for more than 5 yrs. Misch et al. (2006) stated only that
98.8% (95%CI: 97.8-99.8). Pooled biomechanical success rate
none of 338 restorations was refabricated. Friberg et al. (2000),
(according to the random-effects model) was 99.9% (95%CI:
through their 14 years of observation, described 2 abutment
99.4-100.0).
screw fractures in one patient and no major construction complication. Cannizzaro et al. (2009) reported the fracture of the
prosthetic ceramic coating in one patient and Goen et al.
DISCUSSION
(2005) mentioned screw loosenings, that do not affect implant
survival. One 8-mm-long implant fractured after 10 mos of
Although SHIs have been historically considered less reliable
functional loading as a single crown in the posterior mandible
than standard implants, in this review, recent publications spe(Grant et al., 2010). Eight papers did not report any information
cifically designed to study SHIs have reported successful results,
about biomechanical complications. Overall, 4 biomechanical
with a pooled survival rate of 99.1% (95%CI: 98.8-99.4) and a
complications were reported on 1346 prosthetically restored
low incidence of biological and biomechanical complications
implants that were investigated in 7 trials for a mean follow-up
after a mean follow-up period of 3.2 1.7 yrs. It may be specuof 3.2 2.6 yrs.
lated that improvements in implant design and surface characteristics, which guarantee higher primary stability and wider
bone-to-implant contact, as well as the elaboration of focused
Data Analysis
surgical protocols and adapted prosthetic restorations, have
The pooled CSR (according to the random-effects model) was
increased the clinical performance rates of SHIs. Comments and
99.1% (95%CI: 98.8-99.4). The sub-group analysis (according
conclusions from reviewed works seem to agree with this. Six
to the fixed-effects model) per study design reported lower CSR
studies (Deporter et al., 2001, 2008; Gentile et al., 2005; Goen
for prospective studies (Fig. 2).
et al., 2005; Misch et al., 2006; Mal et al., 2007) stressed the
The meta-analyses (according to the fixed-effects model) of
importance of the specific implant system used, and Griffin and
survival data pooled by different variables did not show important
Cheung (2004) recognized the implant maximized surface area
changes in CSR between groups (Table 2), except for
as the main contributing factor to the high success rate.
surface characteristics [rough-surfaced, 99.2% (95%CI: 98.9-99.4)
Renouard and Nisand (2006) identified a surgical protocol optivs. machine-surfaced, 94.6% (95%CI: 92.6-96.6)] (for a detailed
mized to achieve high primary implant stability as a prerequisite
description, see Appendix 5). Very low CSR was reported for
of their study on SHI survival; Fugazzotto (2008) and Anitua

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Annibali et al.

J Dent Res 91(1) 2012

Table 2. Meta-analyses of Data on Implant Survival Pooled by Different Variables*

Variables
Surface Characteristics
Rough
Machined
Implant Location
Posterior Maxilla
Posterior Mandible
Anterior Maxilla
Anterior Mandible
Implant Length
5.0-6.0 mm
6.5-7.5 mm
8.0-9.0 mm
Surgical Technique
2-stage
1-stage
Special surgery
Restoration Type
Single crown
Fixed Partial Denture
Full arch (fixed and removable)
Splinting
Single standing
All-short implants
Short and Standard implants

Studies (n)

Implants (n)

Pooled CSR (95% CI)

Homogeneity
Test P-value

I2 (%)

14
4

5253
605

99.152 (98.865-99.440)
94.565 (92.561-96.568)

0.173
0.589

26.1
0.0

10
11
3
3

1845
3400
26
332

99.060
98.330
88.443
96.426

(98.526-99.595)
(89.860-99.910)
(73.763-100.00)
(94.031-98.821)

0.082
0.666
0.333
0.029

41.4
0.0
9.0
71.8

7
9
10

646
1047
4500

97. 98.934)
99.128 (98.380-99.875)
99.179 (98.872-99.485)

0.880
0.009
0.139

0.0
61.0
33.6

8
6
6

1303
3501
681

98.962 (98.385-99.538)
99.187 (98.845-99.529)
98.714 (97.639-99.789)

0.003
0.036
0.757

68.2
58.0
0.0

10
8
3

2266
2482
456

99.310 (98.894-99.725)
99.091 (98.649-99.534)
98.430 (96.983-99.876)

0.901
0.687
0.000

0.0
0.0
87.9

10
7
6

2266
1211
1870

99.310 (98.894-99.725)
99.830 (99.436-100.00)
99.241 (98.770-99.711)

0.901
0.083
0.524

0.0
46.3
0.0

*Analyses were performed according to a fixed-effects model.

and Orive (2010) reported very positive results with SHIs, but
recommended that they be used under strict clinical protocols.
With regard to the prosthetic aspect, although the success of
many different kinds of prostheses has been demonstrated in the
reviewed works (e.g., single crowns, fixed partial prostheses,
cantilevered fixed partial prostheses, full fixed prostheses, overdentures on bars or with retentive anchors), the authors have
recommended precautions, i.e., joining SHIs with standard
implants (ten Bruggenkate et al.,1998), eliminating lateral contacts on mandibular excursions, avoiding cantilevers, augmenting implant numbers, and splinting multiple implants (Misch et
al., 2006).
In this review, implant surface topography seems to have an
impact on short-implant survival, improving CSR when roughsurfaced implants are analyzed [CSR = 99.2% (95%CI: 98.999.4)] vs. machine-surfaced implants [94.6% (95%CI:
92.6-96.6)]. However, this difference should have been a consequence of the small number of studies investigating machinesurfaced implants.
Even though the surgical technique, the implant location, and
the type of edentulism did not seem to affect short-implant
survival, a notable finding is that most of the failures occurred
before prosthesis placement.
It is likely that bone quality and suitable surgical protocols
play a more major role in short-implant prognosis than prosthetic features. The capacity of SHIs to withstand biomechanical
stresses is supported in this review by a large number of
implants (37.9%) being restored as single crowns, reporting

CSR as high as that of implants splinted to other short implants

or to standard implants, and by the high biological [98.8%
(95%CI: 97.8-99.8)] and biomechanical [99.9% (95%CI: 99.4100.0)] success rates recorded. The biological success rate also
takes into account late failures.
However, it is possible that the lack of sufficient follow-ups
in the analyzed papers underestimated the effect of prosthetic
loading on SHIs outcome, and additional implant failures and
biological or biomechanical complications might be expected
over the long term. The work of Friberg et al. (2000) on
machined 6- and 7-mm-long implants, which had the longest
observational period, found that most implant losses occurred
prior to or around the first few yrs of loading, and no major complications occurred over time. In any case, insufficient findings
have been produced on MBL. Only 6 papers calculated progressive MBL around implants, and only 3 (Friberg et al., 2000;
Deporter et al., 2001; Renouard and Nisand, 2005) described the
range of bone loss observed, which has a more significant clinical meaning than the statistical average. Moreover, it was not
possible to compare the data gathered from the selected studies,
since some referred to the baseline at implant insertion, while
others cited the time of prosthetic connection. Within the limits
of the little amount of data, MBL around SHIs does not exceed
the criteria accepted for standard implants (Albrektsson et al.,
1986). It should be noted that 2 mm of bone loss around a 6-mmlong implant corresponds to nearly half of the entire implant
length, and therefore should be interpreted differently on clinical
grounds. Actually, to aid clinical interpretation, the success rate

J Dent Res 90(1) 2012

Short Dental Implants: A Systematic Review

of SHIs should not be compared with the success of longer

implants placed in the native jawbone, but should be compared
with the success rate of the advanced surgical techniques necessary to place standard implants in resorbed posterior jaws. In
recent systematic reviews of the literature, Chiapasco et al.
(2009) found that the survival rates of implants placed in the
maxilla and mandible reconstructed with onlay bone grafts were
79.5% (follow-up, 6-240 mos) and 94.8% (follow-up, 6-90 mos),
respectively; the CSR of implants placed in the augmented maxillary sinus was 95% (follow-up, 6-144 months); that in vertical
distraction osteogenesis procedures was 95.9% (follow-up, 6-72
mos), and that in the guided bone regeneration technique protocols ranged from 92% to 100% (follow-up, 6-133 mos)
(Chiapasco et al., 2006). They concluded that priority should be
given to simpler approaches.
The two randomized controlled trials included in our review
addressed these issues. Cannizzaro et al. (2009) studied the
efficacy of 10-mm-long implants inserted into maxillary
sinuses augmented according to a lateral approach technique, vs.
8-mm-long implants placed in crestally augmented sinuses
according to the Cosci technique. Thirty-eight SHIs and 44
standard implants were placed and followed up for 1 yr after
loading. There were no statistically significant differences
between the procedures, but more failures and complications
occurred when the most invasive procedure was used. Moreover,
12 out of 17 non-participating patients refused to undergo the
lateral approach sinus lift and preferred SHIs.
Felice et al. (2010) investigated whether SHIs could be an
alternative to standard implants placed in vertically augmented
posterior mandibles. Sixty SHIs and 61 standard implants were
placed and followed up to 1 yr after loading. They concluded
that there were no significant differences in bone loss between
groups, but the augmentation procedure required a longer healing time, further technical skills, and augmented costs, and
caused post-operative paresthesia of the alveolar inferior nerve
in a highly statistically significant manner.
A limitation of this review was that most (72.6%) of the SHIs
investigated were 8, 8.5, or 9 mm long. The number of 5- and
6-mm-long implants (n = 646, 10.4%) was very small, so that
any conclusions about their clinical outcomes should be drawn
with caution.
Moreover, the evidence obtained should be considered as
moderate. Fourteen of the selected studies were observational
studies, and 12 of these were retrospective trials. The subgroup
meta-analysis of survival by study design reported a slightly
higher CSR for retrospective studies. The high susceptibility to
bias of this kind of study might suggest our results to be optimistic. Other questionable issues of the reviewed papers are
sample size and follow-up duration. It has been speculated that
for detection of a difference in implant survival between 85%
and 95% in a statistically meaningful manner, a controlled study
needs to include 135 implants in each arm, for a total sample
size of 270 implants (Eckert et al., 2003). Excluding the existence of the control group, 9 studies provided an adequate
sample size. In addition, 1 of 2 very-large-sized studies was
conducted by one single practitioner who presented a clear conflict of interests, being the owner of the company of the implants
used (Anitua and Orive, 2010).

31

Concerning the follow-up duration, the mean observational

period was less than 5 yrs, and only 1 study produced data after
10 yrs. The decision to include articles that reported a mean
follow-up period of at least 1 yr after prosthetic loading was
supported by: (1) results from published studies (strand et al.,
2004; Berglundh et al., 2005; Cochrane et al., 2009) showing
that most marginal bone remodeling occurs between implant
placement and prosthesis delivery, while little changes continue
up to 5 yrs post-loading; and (2) the idea of increasing the number of eligible studies and therefore the number of implants
susceptible to the analysis of our primary outcome (CSR).
Moreover, no specific measures were taken in this review to
analyze for a cluster effect, and losses to follow-up were also
not considered. The results presented should thus be interpreted
descriptively.
In conclusion, short implant-supported prostheses appear to
be a valid option in the treatment of the atrophic jaw. High survival rates [99.1% (95%CI: 98.8-99.4)] and low incidence of
biological and biomechanical complications are reported after a
mean follow-up period of 3.2 1.7 yrs. Surgical technique,
implant location, and type of edentulism and prosthetic restoration did not affect short-implant survival. Improvements are
possible, with rough-surfaced implants preferred. Randomized
controlled trials and prospective studies with longer follow-up
times and larger samples are necessary to validate the current
findings.

ACKNOWLEDGMENTS
We thank Dr. GianLuca Di Tanna for statistical analyses. The
authors received no financial support and declare no potential
conflicts of interest with respect to the authorship and/or publication of this article.

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